WOMEN 'S HEALTH AND MENOPAUSE : - National Heart, Lung ...

or hypotrophic, 24 percent were proliferative, 24
percent were secretory (30 percent of those showed
luteal delay), and 9 percent showed hyperplasia. 8
Endometrial hyperplasia, a premalignant lesion,
may be simple or complex. Risk for transformation
to cancer is much greater when atypia is present
(table 10–1). 9,10 Endometrial hyperplasia can revert
to normal with administration of a progestin. In a
study of 85 patients with endometrial hyperplasia,
long-term progestin treatment provided uniform
protection against malignant transformation in the
65 without cytological atypia; in the 20 with atypia,
however, endometrial cancer developed in 25 percent,
even after 2–7 years of progestin treatment. 11
Whereas hyperplasia is uncommon in young
women with normal menstrual cycles (1 percent),
it is frequently found in the transition period
women (6–13 percent) 12 or in women presenting
with abnormal bleeding (4–30 percent). 13
In patients with abnormal uterine bleeding, cancer
of the reproductive tract is found in < 10 percent of
those who are in the menopausal transition but in
about 25 percent of those who are postmenopausal. 5
Although cancer is not the most common etiology,
perimenopausal bleeding should be considered secondary
to malignancy until proved otherwise.
TABLE 10–1
Risk for endometrial cancer increases with age
until menopause when it begins to decrease. 14
Other risk factors include diabetes, 15 chronic
anovulation, obesity, and estrogen-producing ovarian
tumors. There are two types of
endometrial cancer. The more prevalent
and less aggressive occurs in
obese, younger women with high
concentrations of circulating estrogen
and in postmenopausal women
receiving estrogen without progestin.
The second, more aggressive type
affects older women without signs of
hyperestrogenism. Use of unopposed
estrogen increases a postmenopausal
woman’s risk for adenocarcinoma of the
endometrium by twofold to ninefold, compared
with no estrogen use, and there is a clear association
between the duration of replacement therapy
and risk. 16–18 Although long-term use of unopposed
estrogen, even in very low dosages, in postmenopausal
women is the single most important
modifiable risk factor for endometrial cancer after
obesity, cases of endometrial cancer have been
reported during long-term estrogen-progestin
replacement therapy, 19 more frequently with cyclic
use of progestins18,19 Endometrial
hyperplasia
can revert to
normal with
administration
of progestin.
than with continuous combinations.
Menopausal women treated with tamoxifen
Probability That Untreated Endometrial Hyperplasia Will Progress
to Carcinoma
Type of Hyperplasia Cytologic Atypia Progression to Carcinoma (percent)
Simple Absent 1
Complex Absent 6
Simple Present 7
Complex Present 33
Sources: Data are from Kurman et al. 9 and Baak et al. 10
205